Showdown 2020

Tom Frieden

Heroin Nation

HEFFNER: I’m Alexander Heffner, your host on The Open Mind. Joining me today is the nation’s chief doctor, Tom Frieden, director of the Centers for Disease Control & Prevention, where he launched his esteemed medical career as an epidemic intelligence service officer at the New York City Health Department. As Ebola terrorized people across hemispheres, you may recall Dr. Frieden’s steady leadership during this 2014 crisis. Besides stamping out the disease when cases re-emerge, still, the Center is charged with forecasting and preparing for the next epidemic.

The New England Journal of Medicine reports a significant chance that a disease substantially more infectious will occur sometime in the next 20 years. So, I do wonder the Doctor’s explanation for why the clock keeps ticking on this overdue bomb. But first, let’s focus on the plague in our own backyard: heroin overdoses. In rural and suburban America, 120 mortalities a day. Doctor, it’s a pleasure to have you here, and I have to ask, what’s going on?

FRIEDEN: Well, thanks so much for having me. You can’t look at heroin in isolation. You have to look at it as the class of drugs it is. It’s an opiate. And in this country, over the past 15 years, we’ve seen a quadrupling of prescriptions and deaths from prescription opiates. Drugs like Oxycontin and Fentanyl. Those drugs are being used very widely in healthcare practice. And three out of four people using heroin, today, are likely to have started with a prescription opiate.

That’s one of the things that we need to do to address it. We’ve also seen a separate phenomenon. Heroin seems to have gotten cheaper and more readily accessible. Apparently, I’m told, the cartels have improved their supply chain management. That means that heroin is less expensive and available to people in more places. And even with highly addictive drugs like heroin, there’s a law of supply and demand. If the prices go down, the use goes up. So, we need an all-of-society response, to stop people from getting addicted in the first place by improving prescribing patterns, to provide treatment to those who are addicted with things like buprenorphine and methadone, and to have law enforcement continue to intensify the work to stop the spread of illegal drugs into the U.S. and around the U.S.

HEFFNER: The demography of, of this particular crisis is centralized. Uh, suburban communities have faced the brunt of this, uh, assault on families. And I’m very interested, from your experience with Ebola. There was a dimension of that, because it originated in Africa, and there was a, a racial element. And in this case, 90% of white people in this country, Caucasians, are the victims. How do you interpret this racialized dimension of the heroin problem?

FRIEDEN: Every community is different. Every community has its own challenges. What we’re seeing with opiates is, uh, largely in rural areas, but also suburban and urban areas, a massive use of prescription opiates. Uh, we had a horrific outbreak last year in Scott County, Indiana. Southern, poor, rural Indiana area, where, uh, in a town of just 4,300 people, you had, uh, 181 new HIV infections among people who were using a prescription opiate and shooting it up, using needles to inject it.

I trained in medicine, here in New York City, in the 1980s. I took care of hundreds and hundreds of men and women who died from HIV because of injection drug use. And for a whole generation, really, there was very little injection drug use. In fact, if you just look over the last decade, the number of people getting infected with HIV by injection drug use has come down by more than two-thirds. But now, just in the past few years, we’re seeing a new phenomenon. People addicted to opiates through prescription painkillers, then going on to inject those painkillers, or heroin.

HEFFNER: What is the stigma? You hear a lot about the stigma associated with heroin.

FRIEDEN: Well, interestingly, it’s very different. Uh, heroin used to be thought of as an inner-city drug. Something that was, uh, not used in, uh, rural areas, not used in suburban areas. But, now we’re seeing heroin, some of it, laced with powerful drugs like Fentanyl, widely available and increasingly used. We’ve seen a near tripling of deaths from heroin, just in the past few years. So, it’s, uh, a big problem, and getting worse.

HEFFNER: So, from a psychological perspective, as well as the medical perspective, what are you doing?

FRIEDEN: Well, there’s a, I think, the way to think of this, is two groups of people. One group of people are people who are currently addicted to or dependent on opiates. Those individuals need services, whether it’s methadone, buprenorphine, or other programs that treat their addiction. Addiction is a brain disease. It changes the wiring of your brain. And people will, uh, sacrifice anything to get the drug. That’s what it, addiction means. So, for those people who are addicted, we need services.

For everyone else, we need to improve prescribing patterns, so we’re not getting more people addicted to these very dangerous drugs. That means, if you’ve got a bad back, if you’ve got a headache, if you’ve got chronic non-cancer pain—we’re not talking about end-of-life or severe pain in the hospital with a surgical procedure—but if you’ve got a chronic pain syndrome, odds are you’re going to be more harmed than benefited by opiate painkillers.

HEFFNER: So, how, where do you start in terms of accounting for prescription drugs in the hospitals?

FRIEDEN: Well, uh, one of the things that we’re doing is working to establish guidelines for the prescription of opiates for chronic pain. Uh, there’s a risk-benefit ratio to these things. The risks of opiates, these are, uh, pills, for chronic pain, uh, include addiction. You take just a few of these pills and you can get addicted for life, and death. You take a few too many and you stop breathing. And the benefits for non-cancer, chronic pain are basically unproven. So you have unproven benefits, but huge risks. And that risk-benefit calculus is something we need to get doctors and patients talking about and thinking about more.

HEFFNER: What is your blueprint, ultimately, for resolving the epidemic?

FRIEDEN: Improved prescribing for pain. Improved treatment of addiction. Reduce the availability of addictive substances that are illicit. Uh, work with communities so that there are alternatives for people socially and economically. And, because we don’t have all of the answers, look at the data, and use analysis of the data to se-, uh, sequentially improve the programs, over time.

HEFFNER: And how are you advising the president and his team in terms of policy alternatives that are not being employed now to, um, shift our regulatory scheme so that, uh, it does not … ensnare victims in a legal process that is unfair?

FRIEDEN: There’s a broad consensus, I think, across the political spectrum, across the country that we need to treat addiction as a disease. Of course, we need to ensure that crimes are appropriately responded to, prevented, and punished, as needed, but addiction is a disease, and we need to see it as such, and treat it as such. We also need to prevent it. It’s a preventable disease, preventable by not exposing people to these dangerous medications unless it’s absolutely necessary.

HEFFNER: I wanted to read, from the New York Times, a quote that’s attributed to the late Daniel Patrick Moynihan, our native, uh, Senator here: “Since the desire of man to alter his state of consciousness is as old as human history, and technology continues to provide a breathtaking array of drugs capable of producing everything from oblivion to nirvana, I think it’s safe to assume that we may never win a war, a war against drugs,” or the war on drugs. Accurate?

FRIEDEN: Well, it is certainly the case that people will always seek out and use substances that change their mental status. It’s not the case that it’s inevitable that we’ve had a quadrupling in prescriptions of opiates and deaths from opiates. That’s a manmade problem. And the one good thing about manmade problems is that we can make them better.

HEFFNER: I couldn’t help but also notice, in covering the recent story about, kind of a grave mortality risk among, um, white people, the link to suicide, and, um, the, the suicide rate, uh, among that same population has quadrupled, as well. What explains that? Is that beyond the heroin issue?

FRIEDEN: So the recent analysis showed that, among white middle cla …, well, middle-aged white people in the U.S., death rates actually increased, and that’s very unusual. You never like to see a death rate increase in any group over time, and it’s unusual. We don’t usually see it. There were three causes of that increase. The first, and the leading cause, was overdose. And that’s being driven by the opiate epidemic.

The second leading cause was an increase, not as sharp, but an increase in suicides. And that’s something that’s very challenging to address. We have some ways to prevent suicide. Uh, it’s a terrible tragedy. Better treatment of depression, uh, removing some of the means of suicide can reduce numbers. Uh, better mental healthcare, better crisis intervention, uh, better medical professionals recognizing the signs and referring people for care.

The third big reason for the increase was liver disease. And that’s also related to drug use. That’s being driven by hepatitis C. We’re seeing a big increase in hepatitis C deaths as, uh, a group of individuals or cohort of people who have a higher risk of hepatitis C, uh, age in, uh, more and more are having liver failure, cirrhosis, and death from liver disease.

HEFFNER: And tell our viewers about the evolution, from your time here in New York City. Because, the critics of our obsession with this issue, say that it is unfairly racialized, and we should be concerned with the urban plight. You know, drugs are still harming people of color in a concentrated manner. Uh, have we, um, become, um, oblivious to other concerns as a result of, of this epidemic?

FRIEDEN: The challenge of public health is to protect the public’s health in each community from whatever the preventable threats are in those communities. That means, in urban areas, we may be dealing with a different set of issues from the issues in rural areas. And in all areas, though, we’re seeing a big increase in prescription overdoses. And there are things we can do. More access to Nalaxone or Narcan, to reverse overdose. Better prescribing, better treatment. Uh, we do have tools at our disposal, but we don’t yet have real huge success stories, uh, across the country to learn from. That’s why each community, each state, needs to see what they can do to drive those death rates down. Then we can all learn from that and scale up the things that work.

HEFFNER: Collectively, Doctor, we have a most daunting challenge. I alluded in the intro to a ticking time bomb. And your work, from the outset, was studying the origin of epidemics and, and really being an intelligence officer on behalf of our population. What’s next? We hear each year about influenza, will this be the year? Uh, but, within the CDC, what are you predicting could be the next epidemic?

FRIEDEN: We don’t know what the next pathogen that causes an epidemic will be. We don’t know where it will come from. We don’t know when it will happen. But we do know there will be a next time. That’s why it’s so important that we expand programs that we call “global health security.” To strengthen the capacity of countries all over the world, to find a threat when it first emerges, stop it promptly there at the source, before it spreads to their neighboring countries and to us, and prevent it wherever possible.

If we had had basic systems in to track, find, and stop outbreaks, the West Africa Ebola epidemic could have been stopped a year ago. If we had had systems in place, SARS wouldn’t have been nearly as bad 10 or 15 years ago. And even decades ago, if we had had systems in place, we could’ve found HIV earlier and perhaps stopped it be … before it became such a horrendous global pandemic. We don’t know what the next HIV or SARS or Ebola will be, but we do know that there will be one. And unless we improve our abilities in other countries to find and stop threats, and in this country to stop the spread of terrible problems like drug-resistant bacteria, we will face avoidable suffering and death.

HEFFNER: What was the most critical lesson learned from the Ebola experience, which is active and ongoing?

FRIEDEN: The single most important thing that Ebola shows us is that a weak link anywhere in the world is vulnerability everywhere in the world. Anywhere there’s the possibility that a disease can spread unchecked until it gets out of control raises the possibility that, with disease just a plane ride away, it could affect us here. But, even in countries with not very strong health systems, but adequate public health infrastructure, they’ve been able to find Ebola, stop it, and prevent it from spreading. That’s what we need to have all over the world.

HEFFNER: I want you really to reflect on this question, Doctor. Why have we not experienced the, the great influenza of this millennium?

FRIEDEN: Influenza is, without a doubt, the scariest of all of the infectious diseases, to those of us who work in public health. Even in an average year, it kills tens of thousands of Americans, and sends hundreds of thousands to the hospital. But, in a bad year, it can be many multiples of that. And the 1918-1919 pandemic was the worst acute disease epidemic of the past century.

Of course, HIV is also a disease that’s killing tens of millions of people, so it’s not just influenza that can do this. But, influenza, because it comes back every year, because it changes every year, and because there is the possibility of influenza organisms, uh, joining from the animal world—avian or, uh, or, or swine flu, joining with human influenza to create new forms of influenza that are highly lethal and highly transmissible, it’s a disease that we need to continue to improve our readiness for.
HEFFNER: But we do know that our genomic data can be instructive in terms of how we combat that next pandemic. Is there any kind of active partnership between your organization and NIH to fuel that process?

FRIEDEN: We work very closely with NIH, and, while they focus generally on the human genome, we focus on the microbial genome. We’ve been able to do rapid whole-genome sequencing, and it’s really revolutionized the way we do disease detection. So, we’re able to find outbreaks sooner, we’re able to figure out where diseases are spreading, which we may not have been able to figure out before, and, in the case of influenza, we’re able to make better vaccines by working with the genome to ensure that we have a vaccine that grows better and creates more immunities. So, this new technology of whole-genome sequencing is revolutionary, really revolutionizing the way we do disease detective work, as well.

HEFFNER: So, as the detective, as our nation’s chief detective, when it comes to disease, um, what most keeps you up at night?

FRIEDEN: I’m worried that we and the world will not learn the lesson of Ebola. Before Ebola, the world’s system was basically: no accountability of whether the country is ready for a threat, and no assistance for countries that don’t have the resources and need help to get ready. We need to be in a new, post-Ebola world, where there is transparency and accountability for how ready countries are, and cooperation and partnership to help countries get ready, for their own sake, and for ours.

HEFFNER: The, it was noted, in a recent Reuters story, that it normally takes up to 18 months to set up a trial. Um, to what extent is it imperative that you are able to do trials for diseases you may anticipate may have a considerable scale. And are you equipped to do that today?

FRIEDEN: It’s very challenging to do clinical trials in the middle of an epidemic. Uh, nevertheless, it’s been done in Ebola, we wish it had been done sooner, but it’s been done, and it is something that has not really been done before, so we’re learning that the vaccine looks like it’s highly effective, and therefore, we’re using it in more settings. Uh, there, there’s a clinical trial of ZMapp, the antibody treatment for Ebola.

We need to develop more tools, but, even more importantly than that, we need to establish the system, in countries around the world, for laboratories to track infections when they first emerge. Disease detectives to find them. Response systems to stop them. And tracking systems so that we know what’s happening, and can identify unusual patterns right when they emerge, before they get out of hand.

HEFFNER: It’s been long-noted that, uh, the U.S. was, uh … instrumental in the eradication of smallpox. Um, with the … most frightening nightmare of chemical weapons in the hands of ISIS … what kind of universal detection mechanism can, can be activated if the threat that was posed against civilians in Syria could become a national, international threat.

FRIEDEN: Really, for groups that are trying to terrorize a population, there are conventional things like explosives, which is what you saw in Paris, tragically. There are, uh, chemical weapons, for which there are antidotes, in some cases, and supportive care, in others. There are biological weapons, and we have systems to try to find and rapidly counteract those, should those be, if those are ever used. And there’s the radiological possibilities. We look at all of those possibilities, understanding that the world is a dangerous place. We can’t make the risk zero, but what we can do is have our systems at the ready, and always work on making them more prepared, more ready, so that we can keep people safe.

At CDC, we work 24/7 to protect Americans from threats. Whether they’re from this country, or anywhere in the world. Whether they’re naturally occurring like Ebola and flu, or manmade, like anthrax. And, uh, whether they’re infectious diseases or injuries, non-communicable diseases or other health problems.

HEFFNER: It sounds like you are more concerned about the biology of mutation than the manmade issues, is that fair?

FRIEDEN: There really are, are three big threats that we face in terms of, uh pathogens, bacterial pathogens, or viral pathogens. The first are new organisms, or new types of organisms: flu, Ebola, MERS, HIV. The second are drug-resistant bacteria. And we’re now seeing some bacteria resistant to all antibiotics. This is a huge risk. It may undermine much of modern medical care. And the third is intentionally created organisms that, either by mistake or on purpose, are unleashed on a population. That’s why we need to get better and better at controlling these organisms, in laboratories around the world.

HEFFNER: What is poised to be a disease where antibiotics will no longer make the fix? You know, be, be a fix? What other diseases are, uh, primed for that kind of resistance, potentially?

FRIEDEN: Each year, in the U.S., about 23,000 people are killed by drug-resistant bacteria. Another 15,000 are killed by an organism called C. diff., which is a result of using antibiotics. Uh, that’s why we’ve asked Congress for funds to set up, in every state in the country, a protection program to protect patients and preserve antibiotics. In communities where we’ve done this, we’ve been able to drive down the rate of drug-resistance by 50% or more, in just a few years. But, we need the resources to protect Americans better.

HEFFNER: In, in, kind of summing up the … peril here, and the potential danger we’re in, um, the former governor, now senator from New Hampshire, uh, proposed recently several hundred million dollars to fight back against the heroin epidemic. Is CDC adequately funded, or, if there was a post-Ebola crisis, would you point to the absence of funding as the, the greatest culpability?

FRIEDEN: Uh, in the budget, currently, we have significant resources to improve global preparedness for Ebola and other health threats. It’s something called the “global health security agenda.” Uh, but that’s one-time funding. So, when that runs out, we will need more money. And for this country our main asks of Congress are funding for drug-resistant bacteria, so we can stop the spread of drug-resistance, and to address the opiate epidemic.

HEFFNER: Are you comfortable with the amount of funding CDC is getting today?

FRIEDEN: Herman Biggs—

HEFFNER: [LAUGHS].

FRIEDEN: …who was one of the great leaders of public health a hundred years ago in New York City said, “Public health is purchasable. Within natural limitations, a community can determine its own death rate.” And, we think that public health is also a best buy. We have a great return-on-investment. With the money entrusted to us by Congress, we protect the American people from threats.

HEFFNER: And did, did the most recent budget situation, the most recent budget impasse affect the CDC?

FRIEDEN: We’ll see. Uh, right now, until December 11th, uh, we’ll find out what next year’s budget is. We have some very high-priority asks in, to address drug-resistance, and to address the opiate, uh, epidemic. And I’m hopeful that Congress will do the right thing, and give us the money we need to protect Americans.

HEFFNER: In your counsel to the President, um, what seems to be the most urgent issue that you keep pointing to, um, when you are engaged in those high-level discussions?

FRIEDEN: Globally, we have a need to strengthen other countries’ abilities to find and stop threats. That’s the only way we can protect Americans here at home. Stop diseases there before they get here. Within the U.S. we have some major priorities, also. Stop the spread of drug-resistant bacteria before it’s too late. It’s not too late yet, but it will be, unless we act quickly, and scale up programs to prevent and treat people who have opiate addiction.

HEFFNER: Dr. Frieden, thanks so much for joining me today.

FRIEDEN: Thank you very much. Great to see you.

HEFFNER: And thanks to you in the audience. I hope you join us again next time, for a thoughtful excursion into the world of ideas. Until then, keep an open mind. Please visit The Open Mind website at Thirteen.org/openmind to view this program online, or to access over 1,500 other interviews. And do check us out on Twitter and Facebook for updates on future programming.